Laserfiche WebLink
PLUMBING PERMIT APPLICATION <br /> EVERETT SUBMITTAL INSTRUCTIONS: <br /> OF EVERETT PERMIT SERVICES <br /> S:Drop off hard copy completed paper application to 3200 Cedar Street 2nd Floor Intake Drop Box. <br /> WASHINGTON CONTACT INFORMATION:(P)425.257.8810 1(E)everetteps@everettwa.gov I(W)everettwa.gov/permits <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION /� <br /> PROJECT SITE ADDRESS: STREET 1010 341- � S t' PARCEL#: , 06 00 <br /> CITY , STATE A ZIP 9 r6 0 <br /> SUITE/UNIT#: FLOOR#: ADDITIONAL LOCATION INFORMATION: <br /> TENANT/BUSINESS NAME(if non-residential): <br /> `� CONTACT INFORMATION <br /> OWNER NAME: �(IQt \ <br /> OWNER MAILING AQ RESS: STREET WID 361 S ' <br /> CITY Gil ev STATE W P ZIP `''t gc)r)-V <br /> OWNER PHONE: `�L�j t6 )l 1 OWNER EMAIL:Wv (-1 1\cr UU co <br /> CONTRACTOR COMPANY NAME: v Y e r <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED): CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): <br /> CONTRACTOR ADDRESS: STREET <br /> CITY STATE ZIP <br /> CONTRACTOR PHONE: CONTRACTOR EMAIL: <br /> PRIMARY CONTACT: t&OWNER ❑CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME:774 cv 6al1 0C_r` 1 CONTACT PHONE:� S C14 5 j 5-1 co3 ` V (4 'n2"1 <br /> `� I �VY 1�( Y ,G t r CONTACT EMAIL: ��//�,�?Ijl ._� �e1/ V1(�� L�► �'1 <br /> PLUMBING PERMIT INFORMATION <br /> VALUATION OF WORK:$ b ASSOCIATED PERMIT#(if applicable): V3 21 ^UPI <br /> (Valuation shall Include the prevailing fair market value of all labor,materials,and equipment needed to complete the work,whether actually paid or not.) <br /> BUILDING TYPE: SFR ❑Townhouse ❑Duplex ❑ADU ❑Multi-Family-#Units: ❑Commercial ❑Accessory Structure <br /> DESCRIPTION OF WORK: 9 P t �Y- 2 1�� <br /> \D U6\VUb Vv\S l a w,\d K _t-- IGt t-C k <br /> PLUMBING PERMIT FIXTURE COUNT (SCOPE OF WORK) <br /> Fixture Fixture <br /> Count List of Fixtures Count List of Fixtures <br /> (Q1y) (Qty) <br /> Backflow Prevention Device(Inside Building)-select devices below: Shower,Tub,or Combo <br /> Fire Service:❑DCDA, Domestic Service:❑RPBA❑DCVA Commercial Sink(3-compartment,prep,floor) <br /> Clothes Washer L4 Residential Sink(kitchen,bath,bar) <br /> Dishwasher Utility Sink(laundry,mop) <br /> Drinking Fountain Z Toilet <br /> Floor Drain Urinal <br /> 7j Hose Bibb Waste/Water Pipe Repair <br /> Ice Maker Water Service Line(Behind meter,private side) <br /> Grease Interceptor Water Valves/Fixtures <br /> Sand/Oil Interceptor Water Heater-Electric <br /> Medical Gas Water Heater-Gas <br /> Roof Drains Other(List Type): <br /> Sewage Ejector PumplSump Pump 1 Other(List Type): <br /> ACKNOWLEDGEMENT:1 have reviewed this application and confirm the information contained herein is true and correct.Work done pursuant to this permit must comply with <br /> current federal,state,and local law.The granting of a permit only authorizes approved work and no deviations therefrom.Deviations must first be authorized in writing from the <br /> Building Official before being authorized under any circumstance.I am the owner,or I am authorized by the owner of this property to perform the work for which application is made, <br /> and I comply with the State C actors Law 18.27 RCW and 296.200A WAC. <br /> City of Everett Official Use Only <br /> PERMIT# <br /> Owner/Authorized Agent Signature Date (Revised 21812021) <br />